Safeguarding Guide for Hospital Doctors

What risk factors make someone more likely to experience abuse?

Abuse and neglect can occur anywhere to anyone; however, there are risk factors that can make a person more vulnerable to abuse.

An adult at risk of abuse may:

• Have an illness affecting their mental or physical health
• Be physically dependent on others
• Have a sensory impairment
• Have a learning disability
• Suffer from drug or alcohol problems
• Have low self-esteem
• Be unable to make their own decisions
• Have a previous history of abuse
• Have negative experiences of disclosing abuse
• Be of increasing age
• Be frail
• Have experienced a lack of access to health and social services or high-quality information

Any child can be at risk of abuse; however, there are a number of factors that can increase a child’s vulnerability to abuse and neglect including, but not limited to:

• Socioeconomic factors such as poverty, poor housing and deprivation.
• Child factors, for example disabled children are more vulnerable to abuse or neglect.
• Family factors such as parental/carer substance misuse problems, parental/carer mental health problems and domestic abuse. These factors may be compounded if the parent/carer lacks support from family or friends and experiences social isolation.
• The parent or carer does not engage with services.
• There have been one or more previous episodes of child abuse or neglect.
• The parent or carer has a mental health or substance misuse problem which has a significant impact on the tasks of parenting.
• There is chronic parental stress.
• The parent or carer experienced abuse or neglect as a child.
• A family history of maltreatment.
• Being in care, a looked-after child.
• A history of offending, either parent or child.

These lists are not exhaustive, and other people might also be considered to be adults or children at risk.

The types of abuse children can encounter

Statutory guidance across the four countries of the UK describes four main categories of child abuse, and these definitions will normally be reflected in local organisations’ policies and procedures.

The four categories are:

• Physical harm/abuse – this may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child/young person. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child/young person. Harm can also occur due to practices linked to faith and culture, for example, Female Genital Mutilation (FGM).
• Emotional harm/abuse – this is the persistent emotional maltreatment of a child/young person such as to cause severe and persistent adverse effects on the child/young person’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child the opportunities to express their views, deliberately silencing them or “making fun” of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond a child’s developmental capacity, as well as overprotection and limitation of exploration and learning, or preventing the child from participating in normal social interaction. It may involve seeing or hearing the ill treatment of another. It may involve serious bullying, including cyberbullying, causing children/young people frequently to feel frightened or in danger, or the exploitation or corruption of children/young people. Some level of emotional abuse is involved in all types of maltreatment of a child/young person, though it may occur alone.
• Sexual abuse – this involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetrative acts, for example rape or oral sex, or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may include non-contact activities, such as involving children in looking at, or in the production of, pornographic sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse, including via the internet. Sexual abuse is not solely perpetrated by adult males; women can also commit acts of sexual abuse, as can other children.
• Neglect – this is the persistent failure to meet a child/young person’s basic physical and/or psychological needs, likely to result in the serious impairment of the child/young person’s development. Neglect may occur during pregnancy, for example as a result of maternal substance abuse, maternal mental ill health or learning difficulties or a cluster of such issues. Where there is domestic abuse and violence towards a carer, the needs of the child may be neglected. Once a child is born, neglect may involve a parent or carer failing to:
  – Provide adequate food, clothing and shelter, including exclusion from home or abandonment.
  – Protect a child/young person from physical and emotional harm or danger.
  – Ensure adequate supervision, including the use of inadequate caregivers.
  – Ensure access to appropriate medical care or treatment, also including neglect of, or unresponsiveness to, a child/young person’s basic emotional needs.

The types of abuse adults can encounter

There are ten types of abuse listed in the Care Act (2014).

These are:

• Physical abuse – this may involve physical violence, misuse of medication, inappropriate restraint or sanctions.
• Sexual abuse – this can include verbal sexual abuse, non-consensual touching, fondling, physical restraint, cornering, tickling, kissing, excessive cleaning of genitals, enemas, intercourse, sodomy, oral sex, invasion of privacy and stalking.
• Psychological abuse – this includes emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, harassment and verbal abuse.
• Financial or material abuse – including theft, fraud, exploitation, pressure in connection with wills, property, inheritance or financial transactions, and misuse or misappropriation of property, possessions or benefits.
• Neglect and acts of omission – including ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services, or withholding medication, adequate nutrition and heating.
• Discriminatory abuse – including racist, sexist or abuse based on a person’s disability.
• Domestic abuse – including psychological, physical, sexual, financial and emotional abuse, and so-called honour-based violence.
• Modern slavery – includes slavery, human trafficking, forced labour and domestic servitude.
• Organisational abuse – including neglect and poor care practice within an institution or specific care setting such as a hospital or care home.
• Self-neglect – includes a wide range of behaviour neglecting to care for personal hygiene, health or surroundings and includes behaviour such as hoarding.

The safeguarding issues hospital doctors may come across

Understanding what abuse and neglect might look like and how to recognise warning signs is an important aspect of safeguarding.

Some examples hospital doctors might encounter may include, but are not limited to:

• A child presents with bruising on the cheeks, ears, palms, arms and feet and on the back, buttocks, tummy, hips and backs of legs, multiple bruises in clusters, usually on the upper arms or outer thighs, bruises which look like they have been caused by fingers, a hand, or an object. Burns of the backs of the hands, feet, legs, genitals, or buttocks and burns which have a clear shape, like a circular cigarette burn. Head injuries caused by a blow or by shaking.
• The child may have repeatedly attended a healthcare setting with different types of injuries in a short period of time or presented in a variety of healthcare settings.
• A hospital doctor in an Accident and Emergency department identifies that a patient is developing a pattern of repeat attendances and triggers a further assessment to determine if the person is in need of additional support.
• The admission assessment of a person with advanced dementia shows signs of self-neglect and flags the need for additional support in eating and drinking.
• Disclosure by an adult or child of abusive activities.
• A series of complaints or comments from patients about staff attitudes on the wards.
• A patient is not receiving basic care to meet their needs.

Hospital doctors must be open-minded when considering the possible cause of an injury or other signs that may suggest that a person is being abused or neglected. Incidents of abuse or neglect may be one-off or multiple, and may affect one person or more. Professionals and others should look beyond single incidents or individuals to identify patterns of harm. Repeated instances of poor care may be an indication of more serious problems and of what we now describe as organisational abuse. In order to see these patterns, it is important that information is recorded and appropriately shared.

When you care for an adult patient, that patient must be your first concern, but you must also consider whether your patient poses a risk to children or young people. You must be aware of the risk factors that have been linked to abuse and neglect and look out for signs that the child or young person may be at risk.